January 22, 2014

On The Anniversary of Roe v. Wade, Get Informed and Get Active

Today marks the 41st anniversary of the Roe v. Wade decision making abortion legal throughout the United States.

As we have seen, however, legality does not equal access. Many states have chipped away at Roe v. Wade; in 2012 alone, 22 states enacted 70 new abortion restrictions, making abortion much more difficult to obtain

There have been numerous stories lately on state abortion battles and where the push will be in 2014 to further reduce abortion access, as (mostly male) politicians, seeking to boost their midterm election profiles, will try to enact more barriers.

Abortion rights activists are going on the offensive. So should you.

For this anniversary of Roe, make a plan to support reproductive choice in 2014. Connect with supporters in your area.

Contact your senators and representatives and let them know you support the Women’s Health Protection Act (S 1696/HR 3471), which would prohibit many restrictions that intrude on a woman’s decision and make it more difficult for physicians to provide abortion services.

Learn about abortion restrictions in your state, and check to see if bills proposing new restrictions have been introduced.

We need to talk more openly about abortion as a health issue for women, and we need to work together to ensure it remains a legal option in the years to come.


January 17, 2014

The Real Danger of the NuvaRing

If you read the recent Vanity Fair article about NuvaRing contraception, “Danger in the Ring,” you could be excused for coming away with the conclusion that NuvaRing is deadly and should be yanked off the market immediately.

But hold on.

NuvaRing, a hormonal birth control that is inserted into the vagina, contains estrogen and etonogestrel, a form of progestin that’s different from what’s in the most common low-dose combined birth control pills. As the Vanity Fair article describes, it is also the subject of ongoing lawsuits about dangerous blood clots.

Marie Brenner’s article focuses heavily those lawsuits alleging harms from the device. What it doesn’t do is put the risk of harms from NuvaRing in the context of other hormonal birth control options, or discuss real magnitude of risk of any of these options.

All hormonal birth control with estrogen carries some risk of blood clots. These are referred to as venous thromboembolism, or VTE, and can be fatal. The risks of the most common combined oral contraceptives are quite small.

The latest FDA safety announcement (2012) estimates that for every 10,000 women taking birth control pills over the course of one year, between three and nine cases of blood clots may occur. In fact, the risks are thought to be higher during pregnancy (five to 20 cases per year for every 10,000 women), and much higher right after birth. By comparison, among non-pregnant women who do not take birth control pills, the number of cases per year ranges from one to five.

Some types of birth control, such as the newer types of pills (like Yasmin and Yaz) containing the progestin drospirenone, are thought to cause a greater risk. These pills have come under more scrutiny in Europe and the United States, with Europe taking a more active role in reviewing the risks. Some women’s health advocates, including Our Bodies Ourselves, have questioned allowing these newer pills to remain on the market because they pose a greater clot risk without offering any major benefits over older types of pills.

The factors to consider when weighing the risks and benefits of NuvaRing or other non-pill alternatives may be different, however, because non-pill alternatives offer more convenience and less chance of missing a dose.

Part of the problem in determining what’s “best” for any individual is the lack of clarity surrounding the increased risk that comes with using NuvaRing. Indeed, different studies have yielded different results: A BMJ study included in the Vanity Fair article found about a 90 percent increase in risk; a FDA paper reports a 56 percent increased risk; other studies have reported “similar” rates of venous thromboembolism between the ring and the regular oral contraceptives.

Looking at the BMJ study, which seems most alarming, lets consider the actual numbers. The researchers explain a 90 percent increased risk would result in 7.8 incidents of VTE per 10,000 exposure years. That means, for example, if 1,000 women each used NuvaRing for 10 years, there would be about 8 incidents of VTE among them in that decade (1,000 women x 10 years = 10,000 exposure years).

So, while different methods of hormonal birth control carry different levels of risk, in general hormonal birth control is very safe for most women. Of great concern, however, is that women aren’t given this information to help in their decision-making.

recent article in Huffington Post describes the FDA approval process for NuvaRing and alleges that Organon — the company that made NuvaRing, which pharmaceutical giant Merck now owns —  maneuvered to keep clot risk information off the product label. To date, the NuvaRing label does not feature the same “black box warning” that the birth control patch carries, which notes a higher risk than the pill. Instead, the NuvaRing product label simply notes that smokers who use the ring may have “serious cardiovascular events.” The NuvaRing website does include some information on comparing the risk to combined oral contraceptives, but the FDA-approved label does not make this as clear by not including it in the black box warning that carries the most important safety information.

Cindy Pearson, executive director of the National Women’s Health Network, and a strong advocate for close review of drug safety, has responded to the concerns:

The most heartbreaking part of the Vanity Fair article are the accounts of women who never knew that the contraceptive ring was delivered a higher dose of hormones and is slightly more risky than pills. No clinician should offer women these products without fully disclosing the risks, and encouraging women to try alternative, safer forms of contraception if they haven’t already done so.

Agreed. While the risk to an individual woman may be low with any of these birth control methods, women must be informed that newer options — including the ring, the patch, and the newer pills — may be more risky than older-style combined oral contraceptives.

In addition, health care providers need to stay on top of the evidence, and should make a point of discussing the benefits and the risks. All women should have the information they need to make good choices for their own health.

Related: Hormonal Contraception and Heart Risks


January 13, 2014

A Woman’s Life Has Ended, but Hospital Insists on Life Support for Fetus Against Family’s Wishes

Right now in Fort Worth, Texas, 33-year-old Marlise Munoz lies in a hospital bed, brain dead after experiencing a blood clot in her lungs. Munoz’s family has been prohibited from honoring her wishes to be removed from life support.

Why? Munoz is pregnant.

When her clot happened, Munoz was 14 weeks pregnant; she’s now 20 weeks pregnant. Texas is one of 12 states in which a pregnancy at any stage invalidates a woman’s advance directive for her end-of-life care. The other states are Alabama, Idaho, Indiana, Kansas, Kentucky, Michigan, Missouri, South Carolina, Utah, Washington, and Wisconsin.

According to the Center for Women Policy Studies, additional states can invalidate a pregnant woman’s wishes and force her to be kept on life support if it’s “probable” that the fetus will develop to the point of live birth. A few more states have similar rules but limit them to women whose fetuses are already viable.

The New York Times notes that some experts in medical ethics have said they believe the hospital is misinterpreting Texas state law prohibiting medical officials from cutting off life support to a pregnant patient. At this point, Munoz’s fetus is not viable outside of her uterus, and it’s unclear whether it was compromised by the amount of time she went without medical attention following her collapse or the subsequent deterioration of her body: 

Mrs. Munoz’s parents and her husband, Erick Munoz, 26, remain in limbo, even as they and other relatives help care for the Munozes’ 15-month-old son, Mateo. Mr. Munoz has returned to his job as a firefighter but continues to sit by his wife’s side at the hospital. She had been due to give birth in mid-May, but the hospital’s plans for the fetus — as well as its health and viability — remain unknown. Mr. Machado [Marlie Munoz's father] said he had been told by the hospital’s medical team that his daughter might have gone an hour or longer without breathing before her husband woke and discovered her, a situation he believes has seriously impaired the fetus. “We know there’s a heartbeat, but that’s all we know,” he said.

Mrs. Machado said the doctors had told her that they would make a decision about what to do with the fetus as it reached 22 to 24 weeks, and that they had discussed whether her daughter could carry the baby to full term to allow for a cesarean-section delivery. “That’s very frustrating for me, especially when we have no input in the decision-making process,” Mr. Machado added. “They’re prolonging our agony.”

Lynn Paltrow of the National Advocates for Pregnant Women has commented:

What is quite stunning about these statutes for women is that they don’t even take into account a woman’s pain. A woman could be in excruciating pain and near death’s door and they still would force her to suffer. These are extraordinary laws creating separate unequal status for pregnant women in which they lose control of medical decision making, the right to bodily integrity and right to be free of excruciating pain.

Not being allowed to die in peace, or watching a family member be denied their wishes, is the stuff of nightmares. This extreme situation, however, isn’t the only one in which pregnant women’s freedoms have been restricted.

In October, there was some media coverage of Alicia Beltran’s case. Beltran had beaten a drug addiction and was 14 weeks pregnant when her doctor and a social worker tried to force her to take an anti-addiction drug and took her to court when she refused.

The National Advocates for Pregnant Women has documented hundreds of U.S. cases of pregnant women who were subjected to or threatened with incarceration, detention, or forced medical or other interventions that the state decided were in the best interest of the fetus — not the woman.

A petition has been launched asking Texas Attorney General Greg Abbott to leave this decision to Marlise Munoz’s family. To learn more about “pregnancy exclusion laws,” read “Marlise Munoz Case Shines Light on Dehumanizing ‘Pregnancy Exclusion’ Laws,” by Lynn Paltrow and Katherine Taylor.


January 8, 2014

False Alarms Remain a Huge Problem with Mammograms Used for Breast Cancer Screening

Breast cancer detection has become a more controversial subject over the past several years, with routine screening mammograms — the kind many women are encouraged to undergo starting in their 40s — drawing more scrutiny.

More and more, researchers and clinicians are acknowledging that screening mammography has a high rate of false alarms, causing worry along with sometimes unnecessary treatment.

annual mammogram benefit harm tradeoff chartH. Gilbert Welch, a professor at the Dartmouth Institute for Health Policy and Clinical Practice, recently wrote an excellent New York Times op-ed exploring the difficult science around breast cancer screening. Explaining the findings of a study on the benefits and harms of screening mammography that he and Honor J. Passow, also of the Dartmouth Institute, published last month in JAMA Internal Medicine, Welch asks how much overdiagnosis we’re willing to tolerate compared to the possibility of reducing deaths from breast cancer.

Using data from radiologists who perform mammograms, Welch and Passow concluded that among 1,000 40-year-old American women screened annually over the course of a decade, between 0.1 and 1.6 women will avoid dying from breast cancer. (See chart at left; click to view full size.) A staggeringly high number — between 510 and 690 women — will have at least one false alarm (60-80 of whom will undergo a biopsy), and up to 11 women will be overdiagnosed and treated needlessly with chemotherapy or radiation therapy, or surgeries such as lumpectomy or mastectomy.

For 50-year-old women screened annually for 10 years, the numbers are as follows:
* 0.3-3.2 women will avoid dying from breast cancer.
* 490-670 women will have at least one false alarm (70-100 will undergo a biopsy).
* 3-14 women will be overdiagnosed and treated needlessly.

And for 60-year-old women screened annually for 10 years:
* 0.5-4.9 women will avoid dying from breast cancer.
* 390-540 women will have at least one false alarm (50-70 will undergo a biopsy).
* 6-20 women will be overdiagnosed and treated needlessly.

“Overtreatment” sometimes occurs when women receive treatments for cancers that would never have gone on to grow, spread, or cause health problems. In those cases, surgery, chemotherapy, and other treatments don’t provide any health benefit, but there are clear harms. Unfortunately, there is no way to know which cancers would go on to be deadly.

Meanwhile, there is little public awareness that routine screening can lead to both false alarms and overtreatment. A recent online survey of middle-aged Americans, notes Welch, suggests that acceptance of routine screening would diminish if the facts were more readily available.

Welch argues that more research is needed, especially on whether older findings showing that early detection might save lives still matter, now that treatment for breast cancer has changed and improved. He is, however, pessimistic about whether trials will happen that would help answer these questions, or explore outcomes when women choose more or less screening:

Two randomized trials could begin to answer the central question of mammography interpretation: How hard should the radiologist look? Women who view mammography favorably might be willing to be screened under either the current approach or a high-threshold approach — meaning their radiologist would ignore small, likely harmless abnormalities found on a mammogram.Those who view it less favorably might choose that high-threshold approach (knowing that the harms of false alarms and overdiagnosis would be minimized) or forgo mammography completely.

Putting the two trials together, we could finally learn what level of screening minimizes false alarms and overdiagnosis while saving the most lives. Most experts would say that it’s never going to happen. It would cost too much, take too long and need too many subjects.

Maybe they are right. But maybe not. Sure, it would cost millions of dollars. But that’s chicken feed compared with the billions of dollars we spend on breast cancer screening every year. Sure, it would take 10 to 15 years. But it would help our daughters know more. Sure, it would take tens of thousands of women to participate. But maybe they would want to be part of the effort to help sort out the morass surrounding what is one of the most common medical interventions done to American women.

We agree with Welch that more needs to be done — both in terms of research and educating the public about the real risks and benefits of their routine screening decisions.

“A screening program that falsely alarms about half the population is outrageous,” writes Welch, adding:

To be sure, many women are quickly reassured by a second test that their breast is normal. But others — while told they don’t have cancer — are told that their breast is somehow abnormal, that they have dysplasia or atypia, that they are at ‘high risk.’ Whether you blame the doctors or the system or the malpractice lawyers, it’s a problem that needs to be fixed.

Plus: For more information, read our previous posts on breast cancer, including several on what is known about the benefits and risks of routine mammography. Good starting points are: “New Mammogram Guidelines Are Causing Confusion, But Here’s Why They Make Sense,” “Do Screening Mammograms Do More Harm Than Good?“, and “The Benefits and Harms of Routine Mammograms.”


January 3, 2014

How to Fix the “Travesty” of U.S. Maternity Care – And Ensure Women Have a Full Range of Choices

Anna Fettby Anna Fett

“So, when am I going to get a grandbaby?”

We have not even been married a month and already my mother-in-law has begun peppering my husband and me with this loaded question.

Babies are still the furthest thing from my mind. I moved to Cambridge with big dreams of pursuing a master’s degree and then plowing onward toward doctoral studies. I know very few people who attempt graduate studies and motherhood simultaneously, and for me the former currently takes precedent over the latter.

Besides the occasional prodding from my family, I rarely think about becoming a mother — that is, until I happened to read a startling headline on the JAMA Forum that caught my attention: “Transforming the Costly Travesty of U.S. Maternity Care.”

My curiosity was piqued; while I knew there are problems in the healthcare system, I was unaware that maternity care in particular was suffering a “travesty.”

The article by Dr. Diana Mason begins by ranking the United States as 46th in the world on maternal mortality “with a rate that has doubled since 1987 and is twice that of 31 other nations.” I was shocked.

The fact that the United States could be so far behind other countries was disturbing, but even more troubling was my ignorance on this issue. How did I not know this? Why are we not all discussing the quality of maternity care?

Moreover, how could this be? — especially given the fact that maternal and newborn care is also the most costly reason for hospitalization in the United States.

My brain attempted to process this debacle. We are paying too much for maternal-newborn care without meeting the same standards of quality of many other countries in the world.

Even though pregnant women in America comprise “a largely healthy population that needs few procedures or technological interventions,” writes Mason, the system is set up to encourage unnecessary procedures, such as cesarean sections — “now the most common operating room procedure in the United States” — despite the fact that normal vaginal births cost 30 percent less.

Suddenly “travesty” did not seem such a stretch.

The goal of Mason’s article is to develop ways of improving maternal-newborn care while also reducing costs, which she believes can be done by shifting to the midwifery model of care. I admit hearing the term “midwifery” instantly conjured images of the Middle Ages for me, but in reality midwives still play prominent roles around the world, and in the United States there is a push to expand midwifery services.

There are now 250 birth centers that follow the model that “maternity services should be provided by certified and licensed midwives and family physicians,” while obstetricians should be reserved for “high-risk pregnancies.”

Maternity care at these facilities could be a much more cost effective option than hospitals if health insurance companies and Medicaid were required to pay “birth centers at 100% of the rate of hospitals for the same or equivalent codes, such as for normal vaginal deliveries,” writes Mason. Families have difficulty taking advantage of what would be a cheaper option because their insurance does not cover deliveries by family physicians or midwives.

As I absorbed this article, a deeper concern struck: The transformation that Mason envisions must also encompass the American way of thinking about maternity care. Instead of viewing the professional provider as the one who delivers a mother’s newborn, the midwifery framework holds that the mother gives birth “with the support of the professional” and “with physician and hospital back-up as needed.”

If we aligned our public policy with the midwifery framework, we could appreciate returning the power of choice to American mothers. Women should be able to decide where to give birth — in the hospital, birth center, or home — and they should be able to decide who will attend them: midwives, family physicians, or obstetricians.

But this can only happen after improving insurance and Medicaid coverage, implementing policies that allow women to choose among these options, and ensuring that midwives receive the education and protection they need, as Mason writes, to “practice to the full extent of their training.” Only by tackling the factors Mason raises can we ensure that women have the full range of choices they need to get the maternity care that is right for them and their family.

When, or even if, my husband and I decide to have children, it is a choice that we get to make when it is right for us — despite my mother-in-law’s best attempts at interference. When we have so many choices ahead of us in life, it seems obvious that we should also have options of where and how to receive maternity care.

I am now joining the ranks of those who want to make the transformation of U.S. maternity care a reality.

Anna Fett is a master of theological studies candidate at Harvard Divinity School with a focus in women and gender studies as well as Islamic studies. She will graduate in May 2014.


December 30, 2013

Want the Facts About Women’s Health?

"Our Bodies, Ourselves" Goes to Washington

Members of Congress received copies of “Our Bodies, Ourselves” in 2013.

When people hear that I write for Our Bodies Ourselves, they often share stories of their first encounter with the book. Time and again, people credit “Our Bodies, Ourselves” with helping them to better understand their own bodies, empowering them to make choices for their own health, and alerting them to political issues and sexism around women’s health.

All of us at OBOS absolutely love hearing these stories, from long-time supporters and new readers alike.

If you’re reading this post, though, you already know that Our Bodies Ourselves is more than a book. This blog is where we provide information on current research and public policy, and promote action alerts and responses to health topics making news. Along with our outreach on Twitter, Facebook and other platforms, this is where we publish crucial updates between book editions, and where we dive deeper into important topics.

Your contributions to Our Bodies Ourselves support the work we do here on the blog, and so much more.

Earlier this year, thanks to you, we delivered copies of “Our Bodies, Ourselves” to every member of Congress, capping off the Educate Congress road trip and campaign, inspired by the epically misinformed Todd Akin. In 2014, we will educate more policy makers at the state level, and expand access access to “Our Bodies, Ourselves” on college campuses and health clinics across the country.

Plans for the new year also include a brand new website and boosting coverage of important topics like contraceptionpregnancy and childbirthbody imageabortion and reproductive rights, and politics.

When the first edition of “Our Bodies, Ourselves” was published, the organization couldn’t have imagined the impact of new technologies on women’s health. Today, we’re covering complex advances such as BRCA1 and BRCA2 breast cancer gene patents, reviews of mammography guidelines and methods, and updates on assisted reproductive technology (ART) services, and we’re advocating for a database to track the health of young women providing eggs for those using ART.

In conjunction with our global partners, OBOS is also working to address the health and rights of women serving as paid gestational mothers in domestic and cross-border commercial surrogacy arrangements.

The work of Our Bodies Ourselves continues in books and beyond. All of us at OBOS would like to thank each and every one of you for reading, sharing, and supporting this valuable work.

We hope you will consider a year-end donation to Our Bodies Ourselves to help ensure that we can continue to provide much-needed information and analysis, and share it with readers around the globe.

Tibetan nuns reading "Our Bodies, Ourselves"

Tibetan nuns reading “Our Bodies, Ourselves”


December 24, 2013

Striving for Gender Equity: My Journey to Armenia

Dilijan Armenia workshop Oct 2013

Judy Norsigian and Dr. Meri Khachikyan, coordinator of the Armenian edition of “Our Bodies, Ourselves,” present organizers with copies of the book.

Looking back on 2013, one of the highlights for me was a trip to Armenia where I spoke about gender equity and witnessed a dozen young women organizing around the lack of sexuality education in their community.

I was a featured speaker at a discussion on “Promoting Gender Equity and Breaking Gender Stereotypes,” hosted by the American University of Armenia (AUA), the Women’s Support Center in Yerevan, and the Armenian International Women’s Association. Dr. Bruce Boghosian, AUA president, and Dr. Meri Khachikyan, coordinator of the Armenian “Our Bodies, Ourselves” translation/adaptation project, attended, along with students, faculty, Peace Corps volunteers, and NGO staff and directors,

Domestic violence is a major concern in this small country — as it is in all of the countries where OBOS has global partners. As part of OBOS’s efforts to encourage men’s engagement in violence prevention, we connected a young man on the AUA panel with staff at Jane Doe Inc., the Massachusetts Coalition Against Sexual Assault and Domestic Violence, which provided him with slides about the role men can play in stopping violence.

Another concern addressed by panelists was the growing problem of sex-selective abortion in Armenia (also common in the neighboring countries of Georgia and Azerbaijan). Approximately 115 boys are born for every 100 girls; only China has a more skewed rate.

Following the AUA event, I attended several meetings with members of groups involved in the Coalition to Stop Violence Against Women in Armenia. In a country where government officials and church leaders have at times endorsed or congratulated those committing homophobic and sexist acts of violence, these courageous activists have been known to disrupt high-level meetings to draw attention to women’s and LGBT rights in Armenia.

I also traveled to rural Dilijan with Dr. Khachikyan, where I witnessed the initial organizing efforts of about a dozen young women (and one young man) concerned about the lack of sexuality education in their conservative community. They came up with several excellent ideas about meeting venues that would be safe spaces for young women, as well as ideas for outreach via social media, and were ready to take on problematic cultural practices.

For example, many parents of young women still do a “check the bed for blood” test after a newly married couple spends its first night together, looking for signs their daughter remained a virgin before marriage. If they find blood, they take a basket of red apples to the groom’s parents to acknowledge the young woman’s “purity.” Plastic surgeons now do a brisk business with hymen reconstruction in many parts of the country, even though this is technically illegal.

Despite the numerous issues women face in Armenia, the intergenerational advocacy and critical support provided by a number of European and American funders contribute to the continued growth of a grassroots movement that will improve the health and well-being of women and girls.

Before leaving, Dr. Khachikyan presented each of the young organizers with their own copy of the latest Armenian edition of “Our Bodies, Ourselves.” I was moved by their enthusiasm — as I have been so many times when talking with women about how the book changed their lives.

Plus: Earlier this year, Taleen K. Moughamian, a women’s health nurse practitioner in Philadelphia, wrote about her experience providing health services in Armenia. Learn more about OBOS’s partner in Armenia, “For Family and Health” Pan Armenian Association (PAFHA), and efforts to adapt and distribute women’s health information based on “Our Bodies, Ourselves.” The preface to the Armenian edition is available in English.


December 19, 2013

Cross-Border Surrogacy: How OBOS is Advancing Public Discourse and Action

Women's Rehabilitation Center facilitators in Kathmandu

Women’s Rehabilitation Center facilitators lead community discussions on cross-border surrogacy in Kathmandu / Photo courtesy of WOREC

by Ayesha Chatterjee & Sally Whelan

In an episode that aired on primetime television in 2007, America’s favorite talk show host portrayed cross-border surrogacy as a win for everyone.

Oprah Winfrey blazed her spotlight on an American couple that traveled to a fertility clinic in the Indian city of Anand to commission a baby. In front of an audience of millions, she extolled the benefits of the arrangement for the couple, who can finally have a baby, and for the woman who is paid to become their surrogate, who can finally send her child to school. Yes, many in the audience agreed, there seem to be benefits all around!

Cross-border surrogacy is a contract-based arrangement that uses assisted reproductive technologies, such as in vitro fertilization. It is a lucrative global industry — the heart of which beats in India — and part of a wider, multi-billion dollar market in assisted reproduction. Thousands of individuals, straight and gay, married and not, have hired surrogates to bear their children.

So who would rain on this parade? Why are there “concern trolls” raising difficult questions about a “solution” that seems a boon for everyone involved?

The answer demands a closer look at the supply side — at the lives, motivations, and vulnerabilities of the women who carry and deliver babies for others, most often to pull themselves and their families out of dire poverty. Their marginalized social and economic status creates a power imbalance that makes it impossible to negotiate dignified and fair “working” conditions and, in fact, allows recruiting agents and clinics to get away with exploitative practices.

Scratch the surface, and these arrangements are replete with health and human rights problems: gestational mothers, otherwise known as surrogates, unable to read the contractual obligations to which they consent; minimal compensation and unfair payment schedules; forced seclusion from family (including young children) and community, in dormitories with round-the-clock monitoring; high-risk medical procedures, including high doses of hormones for embryo transfer and mandated cesarean sections; and little or no postpartum follow up, even in cases of unexpected birth outcomes and health emergencies such as hemorrhage, which can occur days or weeks later with fatal results.

In the middle are the children born as a result of these arrangements. Without best practices and regulation, their rights as citizens in cross-border arrangements, their legal parentage and best interest in custody disputes, and their safety in the absence of adequate screening of commissioning parents, hang in limbo while the world catches up.

This is the untold story of cross-border surrogacy — one on which Oprah did not dwell, one that many of us – including many commissioning parents — know little about. In such a story, where the scales are tipped from the start, only one side wins. The other simply settles.

Here is another story. OBOS, with the Women’s Rehabilitation Centre (WOREC) and Sama Resource Group for Women and Health, is responding to ethical conundrums and human rights issues raised by the largely unregulated cross-border surrogacy market and its ability to adapt to lucrative regional niches.

Sama, based in India, uses action research to critically examine cross-border surrogacy practices, articulate the impact on the lives of women, and make policy recommendations. Sama and OBOS provide technical support to WOREC in Nepal as it builds awareness in its nationwide network of Women Human Rights Defenders, assesses the status of an emerging fertility sector — especially along the country’s border with India — and crafts a preemptive response.

Our goal is simple: develop evidence-based, objective and accessible information to ignite broader social dialogue and action on an issue that is layered, laden, and, most importantly, misrepresented by recruiting agents and fertility clinics.

This collaboration is a call for best practices and regulation of assisted reproduction, and a stepping stone to engaging with commissioning parents as allies who can hold the industry accountable. It embodies OBOS’s legacy of bringing important sexual and reproductive rights issues from the periphery to mainstream dialogue.

And, as policy lags behind technology and markets and the media continue to color public perception of a complex human rights dilemma, this collaboration positions us on the cutting edge to ensure cross-border surrogacy moves forward a an ethical option for growing our families and financial stability — making it a true win for everyone.


December 17, 2013

When Off-Label is Safer for Women: The Politics of Medication Abortion

Among the numerous tactics used to restrict abortion access, several states have proposed or implemented laws that impose unnecessary restrictions on medication abortion. These restrictions interfere with evidence-based practices that are considered safer for women’s health.

Some states are requiring that medication abortions follow the exact regimen approved by the FDA back in 2000, though research has since proven that lower doses are safer and just as effective. (The FDA has approved updated labeling since 2000, but these updates have not addressed the commonly used lower-dose regimen; it is not clear whether the drug company plans to submit new data and request these changes.)

The FDA protocol calls for a clinician to provide 600 mg of the first drug, mifepristone, for the patient to take orally, followed 48 hours later by 400 mcg of oral misoprostol. More modern, evidence-based regimens call for only 200 mg of mifepristone, followed later by 800 mcg of misoprostol that is held in the cheek until it dissolves instead of swallowed. The newer regimen also allows for the misoprostol dose to be taken at home.

Guttmacher Institute: State Policies on Medication AbortionBut states looking to make abortions more difficult for women to obtain are requiring physicians to administer the second dose in person. This mean women are forced to make an additional clinic visit — a significant hardship for many patients.

It’s common practice for doctors to prescribe drugs “off-label,” which means in a different way or for a different purpose than what the FDA has specifically approved. This allows doctors to use the most current evidence and their own judgment. Indeed, a new study accepted for publication in the journal Contraception illustrates how the practice of medicine can change to improve patient safety after a drug has been approved by the FDA.

The researchers reviewed Planned Parenthood data from the five years prior to 2006 — the year Planned Parenthood clinics changed their protocol for medication abortion from vaginal to oral administration of misoprostol, and added additional steps (such as STI testing and routine antibiotics) to reduce infection risk — and the five years after.

They found three deaths out of 218,928 abortions before the change, and no deaths among 711,556 abortions after the change. The Planned Parenthood study used the common reduced dose regimen of 200 mg mifepristone followed by 800 mcg of misoprostol. Other studies have also demonstrated the safety and effectiveness of the reduced mifepristone dose.

When politicians insist on the outdated FDA-approved regimen, they are prohibiting the use of the safer approaches.

The outdated FDA regimen, says Rachael Phelps, medical director for Planned Parenthood in Rochester and Syracuse, is “dramatically less effective, has more side effects, is harder for women to use, and increases the likelihood of an additional invasive procedure compared to the evidence based regimen. Mandating the FDA regimen forces doctors to provide substandard medical care and is just plain bad medicine.”

A case challenging such a law in Oklahoma had been set to go before the Supreme Court, but was dismissed following a state Supreme Court ruling that the law would effectively ban all medication abortion in the state. Texas’s controversial HB 2 law also requires adherence to the outdated FDA-approved regimen.

For a quick guide to additional states with restrictions requiring the old regimen or barring remote doctors from supervising medication abortion via telemedicine, view this fact sheet from Guttmacher Institute.

The federal Women’s Health Protection Act (S1696 / HR 3471) introduced this year would prohibit such restrictions. Among provisions addressing telemedicine abortion, hospital admitting privileges, and other targets of recent legislation, the bill would forbid any “limitation on an abortion provider’s ability to prescribe or dispense drugs based on her or his good-faith medical judgment, other than a limitation generally applicable to the medical profession.” Contact your senator or representative to support this Act.


December 13, 2013

Digital Mammography: Is Newer Always Better?

Mammogram machineYou may have noticed last time you got a mammogram that the facility used digital imaging rather than traditional X-ray film.

Why is that? And, are there any benefits to the newer techniques?

In 2009, when the U.S. Preventive Services Task Force (USPSTF) reviewed the evidence and updated its recommendations on breast cancer screening, it concluded there was not enough evidence to assess the benefits and harms of digital vs. film mammography, due to a lack of studies on the effectiveness of the two methods. (To re-cap, the USPSTF recommends that for women with no increased risk of breast cancer, the decision to start screening before age 50 should be an individual one, rather than a general recommendation. After age 50, the USPSTF recommends screening every two years, up to age 74. There has been some controversy about the guidelines due to concerns about harms of routine mammograms – for for more information, see our related posts, The Benefits and Harms of Routine Mammograms and Do Screening Mammograms Do More Harm Than Good?)

The USPSTF noted that both screening methods may detect some cancers that are not identified by the other, but that overall detection is similar for many women. It found that the chance of false-positives (indication of cancer where it doesn’t exist) is similar in both types.

The Digital Mammographic Imaging Screening Trial (DMIST), published in 2005, is the most important trial of digital vs. film mammography for breast cancer screening to date. The study compared the accuracy of both methods in almost 50,000 women and concluded they’re similar in their effectiveness — neither technology was able to detect 100 percent of the cancers examined.

That said, researchers found digital to be the better tool for women under age 50, or who have very dense breast tissue, or are still menstruating. But it showed no benefit in terms of accuracy for women with all three criteria. And there was no difference in accuracy by race, breast cancer risk, or type of digital machine used.

The DMIST trial was not designed to compare differences in mortality rates among women who underwent different imaging — so it can’t answer the all-important question of whether digital mammography could save more lives than film.

Still, as the National Cancer Institute notes, some health care providers recommend women with a very high risk of breast cancer — women with BRCA1 or 2 genetic mutations, for example, or extremely dense breasts — get digital rather than conventional mammograms, even though no studies have shown that digital is better at reducing these women’s risk of death.

When examining a new medical technology, one consideration is how much the technology costs compared with how many years of quality life may be gained by using it. At least one trial has indicated that screening all women with digital mammograms was not cost-effective, because digital costs more and doesn’t improve health outcomes when used so broadly. Targeting women for digital mammography based on age (i.e., using digital for women under 50) appears to be more cost-effective than using film or digital for all women. The study concluded that a shift to all-digital mammography “has the potential to result in health gains for younger women (especially those with dense breasts) possibly at the expense of older women (especially those with non-dense breasts).”

Unfortunately, providers may not give women a choice. Some health care systems have simply switched over to digital, and individual providers may refer women for a mammography without indicating which type they will receive. In some cases, referrals for digital mammography may be linked to a provider’s investment in the machines, since evidence suggests that doctors are more likely to recommend expensive medical technologies when they have a financial stake in them, even if the procedure isn’t supported by medical evidence.

Medicare also reimburses more for digital screening exams than for film, creating a financial incentive for clinics and hospitals to conduct digital scans instead of film ones.

Digital mammography does have other benefits over film: digital files can be enhanced and manipulated in ways film cannot, and electronic images can be readily shared with clinicians at other locations, which may particularly benefit rural and underserved communities using telemedicine for reading and interpreting mammograms. Finally, digital mammograms may have a slightly lower radiation dose than film (although this may not be meaningful in terms of radiation-related risks, since the radiation dose with either type is very low).

These potential benefits may not justify a switch to digital mammography for all women. The USPSTF notes: “Consumer expectations that new technology is better than old may obscure potential adverse effects, such as higher false-positive results and expense. No screening trials incorporating newer technology have been published.”

So, when your doctor refers you for a mammogram, ask:

  • Are you referring me for a digital or a film mammogram?
  • If you are under 50 years of age: Why do you believe I need a mammogram at this time? Am I in a higher risk group? (This is important if you don’t know that you have any factors that may put you at increased risk).
  • Do you have a financial stake in the mammography facility?

You can also ask your insurer if a film mammogram would cost you less. Many women’s screening mammograms are completely covered by insurance, but costs can vary widely, so it’s good to confirm what the charges will be in advance.

A version of this article originally appeared in the November/December issue of The Women’s Health Activist, the newsletter of the National Women’s Health Network.

Photo: themozhi’s pixel display


December 12, 2013

Cochrane Review: The Safety and Benefits of Midwives Overseeing Maternity Care

Midwife-Led Continuity Models Versus Other Models of Care for Childbearing WomenIf you’re pregnant and living in the United State, it’s likely that an obstetrician will oversee your maternity care and childbirth. In other countries, however, midwives commonly provide care, assuming the pregnancy is low-risk.

An updated Cochrane review aimed to figure out whether patient outcomes vary by who is leading the care team.

Cochrane compiles findings from multiple studies into systematic reviews, considered top-notch for determining the best evidence-based care. In this instance, the authors looked at outcomes for moms and babies of what the authors refer to as “midwife-led continuity models of care” — defined as incorporating a midwifery perspective of minimizing routine intervention during birth, and midwives acting as the lead professionals in organizing and delivering care before, during and after birth.

They considered 13 studies representing 6,242 women in Australia, Canada, Ireland, New Zealand and the United Kingdom that compared the effects of midwife-led continuity models of care with other models: eight studies compared it to a shared model of care (responsibility is shared between different care providers); three studies compared it to medical-led models of care (what we’re most used to in the United States); and two studies compared it to various options of standard care, including midwife-led (with varying levels of continuity), medical-led, and shared care.

All of the studies looked at licensed midwives in hospital birth settings.

In the final review, “Midwife-Led Continuity Models Versus Other Models of Care for Childbearing Women,” the authors report that the midwife-led continuity models of care were associated with some benefits, including a decreased likelihood of episiotomy or instrumental birth, and decreased likelihood of preterm birth or loss of the fetus before 24 weeks’ gestation. Women cared for under this model were more likely to have spontaneous vaginal birth; they also had slightly longer labors and were less likely to use any pain relief.

There were no differences between groups in rates of cesarean birth (although the authors suggest more data may be needed), or overall fetal loss or neonatal death. There were no specific adverse effects attributed to midwife-led continuity of care models.

The Royal College of Obstetricians and Gynaecologists (a UK professional organization) essentially agreed with the message of the review, noting that while other types of specialists should be available for high-risk pregnancies and emergencies, “more women with low-risk pregnancies should be given the option of midwifery-led care.”

While noting that additional research is needed, the Cochrane authors’ recommend what has become standard practice in many parts of the world: “Most women should be offered midwife-led continuity models of care and women should be encouraged to ask for this option although caution should be exercised in applying this advice to women with substantial medical or obstetric complications.”

While the midwifery model of care — especially midwife-led continuity care — is not standard practice in the United States, midwives and other health advocates have been working to change that. Some academic medical centers now incorporate midwives into their care teams for hospital births, for example, though not all teams are midwife-led.

In this JAMA News item, nursing professor and American Journal of Nursing Editor Diana Mason argues for increased access to midwives and birth centers for low-risk births to meet consumer choice and to combat the high cost of maternity care. Mason writes:

We need to question the basic framework for designing maternity services: should it be one in which pregnancy and birth are viewed as normal life transitions or as diseases? This is not just a philosophical issue. The midwifery model of care views birthing as a normal physiologic process and involves care that includes the identification of women at risk for complications and in need of management by an obstetrician.

Women’s health advocates are also pushing for broader reform of the maternity care system, including better and increased support of women before, during, and after birth; expanded choice in birth settings; an emphasis on medical evidence; and improved staffing of maternity care teams.

These issues and other concerns are addressed in the 2020 Vision for A High-Quality, High-Value Maternity Care System – prepared for Childbirth Connection’s Transforming Maternity Care symposium — which focuses on woman-centered care that “respects the values, culture, choices, and preferences of the woman, and her family, as relevant, within the context of promoting optimal health outcomes.”

To learn more about the midwifery model of care, check out this excerpt from “Our Bodies, Ourselves,” and the resources from Childbirth Connection. To find a practice with nurse-midwives in your area, try the ACNM’s Find a Midwife search tool.


December 6, 2013

The Ideal Labia is Your Own: Online Sites Push Back Against “Model” Genitalia

labia library
Cosmetic genital surgery on the labia has been of both increasing interest and concern in recent years. Many attribute this to the fact that the most readily available images of vulvas, which happen to be in pornography, don’t tend to show much variation in shape, color, hair, or other characteristics.

A few resources exist to help promote the idea that there is a much wider range of what is normal than we often see in media. The Labia Library, run by Women’s Health Victoria, is a small photo gallery of labia, primarily of white-appearing women. The site also addresses body image concerns in the section Are My Labia Normal?.

Writing in the Daily Life, an Australian publication, Melissa Brock does a terrific job contextualizing the concerns women have about their bodies (and a ridiculous Catch-22 when it comes to censorship guidelines):

In Australia over the past 10 years, medical rebates for labiaplasty (surgical reduction of the inner or outer labia) and vulvoplasty (surgical remodelling of the vulva) have risen from 640 claims in 2000-01 to 1565 in 2010-11, though the real number of procedures is thought to be much more. At the same time, mainstream pornography has become more explicit, showing extreme close-ups of hairless female genitalia. Previously hidden behind a bush of hair, labia are now under close scrutiny. The type typically featured in pornography are known as the “Barbie” or “clamshell” variety, where everything is neatly tucked away. And just to complicate the matter, Australian censorship and print publication guidelines dictate that the inner labia must not protrude beyond the outer labia. Houston, we have a problem. Many women are not designed this way and have started to question whether they are “normal”.

Brock goes on to describe her own experience visiting the online Labia Library:

I was alone in my bedroom on a computer looking at women’s genitals. Surely I was doing something wrong. I would have to clear my browser history. But that thought was short-lived because, devoid of the lingerie, the ambient surroundings and orgasmic groans of pornography, it was fascinating. I never knew what other women actually looked like down there. It was strangely liberating. It turns out I’m not alone – Butera says the site survey has been “overwhelmed by positive comments”. Hannah Cooper, 38, a personal assistant from Sydney, says of the library, “When a friend suggested I check it out, I thought eeek … but it wasn’t gross and it wasn’t sexy. They were all just so different and it makes sense. Everyone has a different face – it follows that people would have different labia.”

On tumblr, the Large Labia Project includes photo submissions from readers who believe their labia are “large” — the point being that all sizes of labia can be “normal” and beautiful. These resources make it easier for us all to see that outside of pornography, everyone is different. Another excellent resource on this topic is Scarleteen’s article “Give ‘em Some Lip: Labia That Clearly Ain’t Minor,” and the accompanying illustrations from Betty Dodson.

In part because of anxieties about the appearance of their genitals and lack of examples of the wide range of genitals, some women have elected to have cosmetic surgery to make their appearance more “normal.” The New View Campaign has a lot of good info on cosmetic genital surgery, including this set of FAQs.

The Royal College of Obstetricians and Gynaecologists (in the UK) recently released an ethical opinion paper on the subject of genital cosmetic surgeries to guide doctors on this issue. The paper emphasizes the lack of high-quality or long-term evidence about the safety, risks or even patient satisfaction with these surgeries, explaining that doctors “must be aware that they are operating without a clear evidence base.”

There are currently no controlled trials or prospective studies investigating the clinical effectiveness or risks of labiaplasty procedures. There are small case reports and a few larger retrospective studies, all of which offer scant descriptions of methodology or study design. Since the surgical studies are authored by the surgeons who performed the operations, there is little independent evaluation.

RCOG also emphasizes that “so-called norms” presented in media are “digitally modified and should be challenged by those who deal with women requesting labial reduction for ‘aesthetic’ reasons.” To learn more about normal vulvas and issues around cosmetic genital surgery, read previous posts:

And, finally, here’s a video on the difference between porn sex vs. real sex, using food as props. It’s more about function than appearance, but still well worth a look. YouTube Preview Image


December 3, 2013

Science Says: Emergency Contraception Does Not Block Implantation of a Fertilized Egg

Last week, in a post about how some types of emergency contraception are less effective or ineffective in women weighing more than 165 pounds, we mentioned that the European equivalent to Plan B One-Step was getting a new label that will note the problem.

Let’s take a look at the other reason for the label change: European health officials have determined — and want to make clear — that the drug “cannot stop a fertilized egg from attaching to the womb.”

This is a big issue, as abortion opponents have long opposed EC on the grounds that it might prevent a fertilized egg from implanting in the uterus. U.S. labels of levonorgestrel-containing emergency contraceptive pills, such as Plan B, don’t directly refute the possibility.

But as The New York Times noted last year, recent science suggests that this is not the case; the pills work only by preventing ovulation and fertilization.

Last week, NYT reporter Pam Belluck noted how the FDA and other health agencies responded to the scientific studies:

References to the possibility of blocking implantation were then removed from the websites of the National Institutes of Health and the Mayo Clinic. And an F.D.A. spokeswoman, Erica Jefferson, said that “the emerging data on Plan B suggest that it does not inhibit implantation.”

On Tuesday, Ms. Jefferson reiterated that view. The drug agency has not moved to change the label, saying manufacturers must request a change. Plan B One-Step’s manufacturer, Teva Pharmaceuticals, declined to comment. It had previously said scientific evidence suggested that the pill did not disrupt implantation.

Although pregnancy is not medically considered to have begun until a fertilized egg has successfully implanted in the lining of the uterus, media coverage around this topic has often obscured this distinction and promoted a false idea that emergency contraception is the same thing as the abortion pill (RU-486) or abortion in general. Medical professionals generally assert that “emergency contraception is not effective after implantation; therefore, it is not an abortifacient.”

Effect on Lawsuits
Hobby Lobby is one for-profit corporation that filed suit to avoid complying with Obamacare coverage for contraception, claiming that forms of contraception that could interfere with the implantation of a fertilized egg are tantamount to abortion. The Supreme Court will hear the case, focusing on whether for-profit companies can be required to provide coverage that may conflict with the private religious beliefs of the business owners.

As Linda Greenhouse wrote in an op-ed about challenges to the contraception mandate under the Affordable Care Act, a coalition of medical groups, led by Physicians for Reproductive Health, filed a brief in the case, noting in part that “the weight of the scientific evidence establishes that the FDA-approved contraceptives and emergency contraceptive are not abortifacients.”

Read Greenhouse’s column for an excellent look at how the religious-based challenges represent a culture war on “modernity.” For more on the lawsuits, SCOTUSblog is a smart resource.

And we highly recommend the Emergency Contraception website for easy-to-understand fact sheets, such as this one: “Does emergency contraception cause an abortion?


November 27, 2013

Worried About the Effectiveness of Emergency Contraception Pills? Here’s An Alternative

Emergency contraception is tremendously important for women seeking to prevent pregnancy after unprotected sex. Activists and public health advocates have worked for years to make EC pills more readily available, and have been successful in getting pills such as Plan B available without a prescription or age restrictions.

Emergency contraception pills containing levonorgestrel (including Plan B) may not be right for every woman and situation, however. Though the pills can be taken up to five days after unprotected intercourse, the pills are most effective (95 percent) when taken within 24 hours and become steadily less effective as more time passes. A different type of EC pill — Ella, containing ulipristal — is thought to keep a pretty high level of effectiveness for the full five days.

News this week has raised another issue of emergency contraception effectiveness: EC pills with levonorgestrel seem to be less effective in women weighing more than 165 pounds, and lose their ability to work in women who weigh more 175 than pounds.

This loss of effect happens regardless of whether women are considered overweight or obese according to BMI charts, or are simply tall — despite headlines that almost exclusively focus on “obese women.”

As Linda Prine of the Reproductive Health Access Project said in an interview with NPR: “This is barely overweight. We’re talking about a BMI over 25. So this is probably more than half of American women. This medication would not work for them.”

The Food and Drug administration is reviewing whether makers of levonorgestrel-containing pills (Plan B, Plan B One-Step, Next Choice, My Way) should be required to revise their labels to include a weight warning. In Europe, the label for one identical product (Norlevo) has already been changed to warn about the loss of effectiveness.

The European label change is what prompted news coverage this week, though the study that informed the change was actually published in 2011.

For that study, researchers reviewed results from two prior randomized controlled trials to look for factors that could explain rates of emergency contraception failure. Not only did they find that overweight and obese women had much higher risks of pregnancy than “normal” weight women (anywhere from double the risk to more than four times greater), but women with a “normal weight” BMI women who are tall also have greater risks of pregnancy.

The authors note that additional research is needed to determine whether these women could be given higher doses of the drug for improved efficacy.

The researchers also found that while Ella (ulipristal) worked at higher weights than levonorgestrel-containing pills, it, too, lost some effectiveness with increasing weight. At about 194 pounds, ulipristal appeared to lose all effectiveness.

Women in need of emergency contraception do have another option, however: the copper IUD (Paragard).

IUDs are intrauterine devices that not only are considered 99.9 percent effective for emergency contraception, but they can remain in place for up to 10 years and are one of the most effective forms of contraception overall. While in the past doctors may have been reluctant to provide IUDs for younger women and women who have not had children, more current research suggests that their concerns about side effects were largely unfounded.

Copper IUDs work to prevent pregnancy by inhibiting fertilization, primarily by preventing sperm from reaching an egg. They may also help to prevent implantation of a fertilized egg, but they do not interfere with an established pregnancy. (It is important to remember that IUDs do not protect against HIV or other sexually transmitted infections, so barrier methods may be needed as well for protection.)

For more information, read more about the safety of prescribing the IUD for teenagers, along with this post on the pros and cons of IUDs. You can also read an excerpt from “Our Bodies, Ourselves” on emergency contraception, and visit the excellent Princeton/ARHP emergency contraception website for more on EC and body size.


November 22, 2013

Top Hospitals Putting an End to Formula Marketing to New Moms

Despite a wealth of evidence that breastfeeding provides the most health benefits for infants, many barriers — including rigid work conditions and lack of family or community support — can interfere with a woman’s ability to start breastfeeding, or to keep breastfeeding for at least six months.

Health advocates have long criticized the popular hospital practice of distributing infant formula to new mothers, because doing so descreases the length of time that women breastfeed — even when they have indicated a desire to try breastfeeding, and sometimes instead of providing lactation support (read this previous post, which discusses a report on Chicago hospitals in low-income neighborhoods).

According to the Centers for Disease Control, 77 percent of infants in the United States start out being breastfed, which is an increase over recent years, yet fewer than half are still breastfeeding at the six-month mark.

Many hospitals have banned pharmaceutical or other industries from providing marketing materials directly to doctors, in order to avoid conflicts of interest, but many hospitals still provide free formula samples directly to patients.

A new report from Public Citizen, however, suggests that more of the top hospitals in the country are agreeing to limit distribution.

The consumer advocacy organization looked at the top hospitals in the U.S. News and World Report rankings, both those with the gynecology specialty and maternal/newborn services and those on the general Honor Roll. It then surveyed those hospitals about their policies and practices, and checked against data from the national Ban the Bags campaign, which grew out of a Massachusetts effort to stop aggressive formula marketing.

Some of Public Citizen’s key findings:

  • Sixty-seven percent of top gynecology hospitals in gynecology reported not giving out bags sponsored by formula companies, formula samples, or other formula-related promotional materials
  • An additional 11 percent (5 of 45) limited samples and sponsored bags to those who request them, moms who are already planning to formula feed, or to Neonatal Intensive Care Unit patients
  • Eighty-two percent (14 of 17) of the best overall hospitals reported having a policy or practice against distributing these materials

Public Citizen recommends that the remaining hospitals on these lists also ban formula distribution, and discuss other interventions that public health departments and state legislatures can take to restrict the practice. As the report notes:

Numerous studies show that women are likely to breastfeed less, and for shorter durations, if they receive formula samples and promotional materials in hospital discharge packs. Formula bag distribution effectively influences new mothers to use formula because it sends a powerful message that hospitals endorse formula feeding, even where breastfeeding in hospitals is promoted.

One major effort to improve the support for breastfeeding in hospitals is the Baby-Friendly Hospital Initiative, endorsed by several major medical organizations. The Initiative sets standards for baby-friendliness, including breastfeeding support. The Initiative’s guidelines and evaluation criteria states that in baby-friendly hospitals, staff members should not receive donations from breast milk substitute providers, and mothers and their families should not be given marketing materials for formula or gift packs containing formula. The Baby-Friendly principles have been endorsed by several major medical organizations.

Ban the Bags provides a toolkit for advocating against these formula sample bags, which can be downloaded from its website, as a resource for taking action in your own community. As Ban the Bags puts it: “Hospitals should market health, and nothing else.”